Medicare AdvantagePrior AuthMedium impact
MA08.018k, Trastuzumab (Herceptin®) and Related Biosimilars, Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)
Independence Blue Cross·Oncology, Hematology·Pharmacy
Effective date
Oct 1, 2025
We identified it
Jun 19, 2026
Summary
This policy establishes coverage guidelines for Trastuzumab (Herceptin®), biosimilar trastuzumab products, and Trastuzumab with Hyaluronidase-oysk (Herceptin Hylecta) for Medicare Advantage members effective October 1, 2025. The billing team must review the specific prior authorization requirements, covered indications, dosing limits, and any prior step therapy requirements outlined in the full policy to ensure compliant claim submission.
Action Required
By October 1, 2025: Billing and clinical teams must obtain and review the complete MA08.018k policy text to identify: (1) specific HCPCS codes for trastuzumab products covered, (2) prior authorization requirements and submission process, (3) covered diagnoses and medical necessity criteria, and (4) any step therapy or quantity limits. Update billing software rules in the system to require prior authorization for affected trastuzumab codes before submitting claims. Train billing staff on the new requirements. Communicate with oncology providers about documentation needed to support medical necessity. Failure to obtain required prior authorization will result in claim denials for Medicare Advantage members.